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Q <br />SWRCB, January 2006 <br />Spill Bucket Testing Report Form <br />This form is intended for use by contractors performing annual testing of UST spill containment structures. The completed,form and <br />printouts from tests (f applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br />I T. A "T TTV TNTi (172 M A TInN <br />Facility Name: LODI FOOD & LIQUOR Date of Testing: 11/23/10 <br />Facility Address: 1225 W. LOCKEFORD ST. LODI, CA 95240 <br />Facility Contact: PAUL Phone: <br />Date Local Agency Was Notified of Testing :9/15/10 <br />Name of Local Agency Inspector (ifpresent during testing): ARIS CACAPIT <br />2_ TESTING CONTRACTOR INFORMATION <br />Company Name: AFFORDA TEST 4162 d Street Galt, CA 95632 (209) 744-0112 Fax: (209) 744-0116 <br />Technician Conducting Test: ❑ Lyle D. Nimmo ® Zane A. Nimmo ❑ David A. Winkler ❑ Felix G. Ramirez <br />5249115 -UT 5263322 -UT 5263373 -UT 5273934 -UT <br />11 Credentials': ® ICC Service Tech. ® SWRCB Tank Tester 11 <br />I QPTT I RTTPWVT TFCTINC_ INMRMATION <br />Test Method Used: ® Hydrostatic ❑ Vacuum ❑ Other <br />Test Equipment Used: TAPE MEASURE, <br />H2O <br />Equipment Resolution: 1/16" <br />2 <br />3 91 <br />4 DIESEL <br />Identify Spill Bucket (By Tank <br />Number, Stored Product, etc.) <br />1 87 <br />[Bucket Installation Type: <br />® Direct Bury <br />❑ Contained in Sump <br />❑ Direct Bury <br />❑ Contained in Sump <br />® Direct Bury <br />❑ Contained in <br />Sump <br />® Direct Bury <br />❑ Contained in <br />Sum <br />Bucket Diameter: <br />11 <br />1 I <br />11 <br />Bucket Depth: <br />12 <br />11 <br />10 <br />Wait time between applying <br />vacuum/water and start of test: <br />__ <br />__ <br />Test Start Time (Tj): <br />1130 <br />1130 <br />1210 <br />Initial Reading (Ri): <br />10 1/2 <br />9 1/2 <br />8 1/2 <br />Test End Time (TF): <br />1230 <br />1230 <br />1310 <br />Final Reading (RF): <br />10 1/2 <br />9 1/2 <br />8 1/2 <br />Test Duration (TF — Tj): <br />HR <br />HR <br />HR <br />Change in Reading (RF - Rj): <br />0 <br />0 <br />0 <br />Pass/Fail Threshold or <br />Criteria: <br />Test Result: <br />Pass ❑ <br />Fail <br />❑ Pass ❑ <br />Fail <br />E Pass ❑ <br />Fail <br />® Pass ❑ Fail <br />Comments — (include information on repairs made prior to testing, and recommended follow-up for failed tests) <br />CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br />I hereby certify that all the information contained in this report is true, accurate, and in full compliance with legal requirements. <br />Technician's Signature: <br />Date: 11/23/10 <br />' State laws and regulations do not currently require testing to be performed by a qualified contractor. However, local requirements <br />may be more stringent. <br />